Global guidelines for the prevention of surgical site infection, 2nd ed.
3 January 2018
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Overview
Surgical site infections are caused by bacteria that get in through incisions made during surgery. They threaten the lives of millions of patients each year and contribute to the spread of antibiotic resistance. In low- and middle-income countries, 11% of patients who undergo surgery are infected in the process. In Africa, up to 20% of women who have a caesarean section contract a wound infection, compromising their own health and their ability to care for their babies. But surgical site infections are not just a problem for poor countries. In the United States, they contribute to patients spending more than 400 000 extra days in hospital at a cost of an additional US$ 10 billion per year.These WHO guidelines which were updated in 2018, are valid for any country and suitable to local adaptations, and take account of the strength of available scientific evidence, the cost and resource implications, and patient values and preferences
WHO Team
Integrated Service Delivery
Editors
World Health Organizations
Number of pages
184
Reference numbers
ISBN: 9789241550475
Copyright
Hypothesis Infectious complications are the main causes of postoperative morbidity in abdominal surgery. Identification of risk factors, which could be avoided in the perioperative period, may reduce the rate of postoperative infectious complications.
Design A database was established from 3 prospective, randomized, multicenter studies. Multivariate analysis was performed using nonconditional logistic regression expressed as an odds ratio [OR].
Setting Multicenter studies [ie, private medical centers, institutional hospitals, and university hospitals].
Patients From June 1982 to September 1996, a database was established containing the information of 4718 patients who underwent noncolorectal abdominal surgery.
Main Outcome Measures The dependent variables studied included surgical site infection [SSI] [divided into parietal and deep infectious complications with or without fistulas] and global infectious complications [SSI and extraparietal and abdominal infectious complications].
Results The rate of global infectious complications was 13.3%; SSI, 4.05%; parietal infectious complications, 2.2%; deep infectious complications with fistulas, 2.18%; and deep infectious complications without fistulas, 1.38%. In multivariate analysis, the following 7 independent risk factors for global infectious complications have been identified: age [60-74 years, OR, 1.64; ≥75 years, OR, 1.45]; being underweight [OR, 1.51]; having cirrhosis [OR, 2.45], having a vertical abdominal incision [OR, 1.66]; having a suture placed or an anastomis of the bowel [OR, 1.48] in the digestive tract; having a prolonged operative time [61-120 minutes, OR, 1.66; 121 minutes, OR, 2.72]; and being categorized as having a class 4 surgical site [ie, obese patients or having a risk factor of a healing defect] [OR, 1.66]. Ceftriaxone sodium therapy was identified as a protective factor [OR, 0.43]. In multivariate analysis, the following 5 independent risk factors for SSI have been identified: the existence of a preoperative cutaneous abscess or cutaneous necrosis [OR, 4.75], having a suture placed or an anastomosis of the bowel [OR, 1.82] in the digestive tract, having postoperative abdominal drainage [OR, 2.15], undergoing a surgicial procedure for the treatment of cancer [OR, 1.74], and receiving curative anticoagulant therapy [OR, 3.33] postoperatively.
Conclusions Our data show that risk factors for SSI and for global infectious complications are disparate. Indeed, only the placement of a suture or having an anastomosis of the bowel in the digestive tract is a risk factor for both SSI and global infections. Some of these factors may be modifiable before or during the surgical procedure to reduce the infection rate or to prevent postoperative complications.
INFECTIOUS COMPLICATIONS are the main causes of postoperative morbidity in abdominal surgery. These complications have an important financial cost and are responsible for significant morbidity., To reduce these complications, it is important to establish the risk factors that increase their incidence using multivariate analysis. If this issue has been already addressed for colorectal surgery, it has not been well studied for abdominal noncolorectal surgery. Although the efficiency of antibiotic prophylaxis for reducing postoperative infectious complications has been demonstrated in previous prospective, randomized studies,- controversy still exists about which specific antibiotic agent to use. Since 1992, the Centers for Disease Control and Prevention, Atlanta, Ga, has modified the definition of surgical wound infection using the term "surgical site infection" [SSI], which includes parietal and deep infectious complications. To our knowledge, no studies reported in the literature consider postoperative global infectious complications including extraparieto-abdominal infectious complications [ie, urinary tract infections, intravascular catheter–induced infections, lung infections, and late infections].The risk factors for SSI and for global infectious complications may differ. Our study estimated the risk factors for SSI and for global infectious complications in abdominal noncolorectal surgery in patients who received antibiotic prophylaxis. Identification of risk factors in the perioperative period may allow for a reduction in the rate of postoperative infectious complications.
A database was established from 3 prospective, randomized, multicenter studies [ie, private medical centers, institutional hospitals, university hospitals] led by the French Associations for Surgical Research on antibiotic prophylaxis in abdominal noncolorectal surgery. The first trial, conducted from June 1982 to September 1986, compared the efficacy of a 24-hour antibiotic prophylaxis [ie, cefotaxime sodium or cefazolin sodium] with a control group who received no antibiotic prophylaxis [n = 3156]. The second trial, conducted from June 1987 to June 1989, compared the efficacy of a single dose of ceftriaxone with 3 doses in 24 hours of cefazolin or cefotaxime [n = 1363]. The third trial, conducted from January 1994 to September 1996 [results of which are still unpublished], compared the efficacy of antibiotic prophylaxis using a combination of amoxicillin and clavulanic acid with ceftriaxone [n = 1269]. The information in this database was reorganized for 5798 patients who underwent an intra-abdominal, nonseptic surgical procedure with at least 1 abdominal incision. The following were exclusionary criteria: aged 17 years or younger, colorectal surgery, septic operations in which an antibiotic treatment was given systemically, patients who were already treated with antibiotic agents or those who received antibiotic agents within the previous 15 days, patients who had a drug allergy, patients who had chronic renal failure, patients treated with allopurinol, patients who had infectious mononucleosis, patients who were pregnant, and patients who were found intraoperatively to harbor an intra-abdominal infection.
The independent risk factors analyzed were divided into preoperative, intraoperative, and postoperative variables.
Preoperative Risk Factors
The preoperative risk factors were as follows: age; sex; height; weight; loss of weight exceeding 10% of the patient's ideal weight; the presence of diabetes mellitus, cirrhosis, ascites, and other disease [chronic heart failure with an ejection fraction of